From the Oxford Project to Investigate Memory and Ageing (OPTIMA),
Department of Pharmacology,
University of Oxford, Oxford, United Kingdom;
fredrik.jerneren@pharm.ox.ac.uk

This study provides clarity to earlier studies that found that B vitamins and/or Omega-3 fatty acids were found to slow brain loss in areas of the brain associated with Alzheimer’s disease.

In a 2010 study, Smith et al. [1] (in the Oxford Project to Investigate Memory and Ageing study) gave 271 individuals with mild cognitive impairment high-dose B vitamins for 2 years. Pre- and post-MRI studies were done, and they demonstrated that the B vitamin group experienced 30-percent slower rates of brain atrophy, on average, and in some cases patients experienced reductions as high as 53 percent.

In a 2012 study, Bowman et al. [2] (in the Oregon Brain Aging Study) reviewed blood nutrient levels in 104 dementia-free elders. They found two nutrient biomarker patterns (NBPs) that were associated with more favorable cognitive and MRI measures: one was high plasma levels of the vitamins B, C, D, and E, and the second NBP was high plasma marine omega-3 fatty acids. They also demonstrated that high trans fat blood levels were associated with less favorable cognitive function and less total cerebral brain volumes.

When this article was pre-released, the New York Times ran a banner headline titled: 4 Vitamins That Strengthen Older Brains. [3]

In a 2013 study, Douaud et al. [4] provided high-dose B-vitamin treatment to elderly subjects with increased dementia risk for 2 years. They found that B vitamins reduced brain shrinkage and reduced levels of plasma total homocysteine (tHcy). This is important because many cross-sectional and prospective studies have shown that high tHcy levels are associated with cognitive impairment, Alzheimer’s disease (AD), and vascular dementia.

The current study also helps explain why some trials that focused solely on the B vitamins or Omega-3s had mixed results. Apparently having high blood levels of BOTH the B vitamins AND Omega-3 fatty acids provides better results in prfeventing the deterioration of the brain of Alzheimer’s patients.

Objective The purpose of this case report is to describe a patient who presented with acute musculoskeletal symptoms but was later diagnosed with multiple deep vein thrombosis (DVT).

Clinical Features An 18-year-old female presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior left thigh. A provisional diagnosis was made of acute myofascial syndrome of the left piriformis and gluteus medius muscles. The patient received 3 chiropractic treatments over 1 week resulting in 80% improvement in pain intensity. Two days later, a sudden onset of severe abdominal pain caused the patient to seek urgent medical attention. A diagnostic ultrasound of the abdomen and pelvis were performed and interpreted as normal. Following this, the patient reported increased pain in her left leg. Evaluation revealed edema of the left calf and decreased left lower limb sensation. A venous Doppler ultrasound was ordered.

Intervention and Outcomes Doppler ultrasound revealed reduction of the venous flow in the femoral vein area. An additional ultrasonography evaluation revealed an extensive DVTs affecting the left femoral vein and iliac axis extending towards the vena cava. Upon follow-up with a hematologist, the potential diagnosis of May-Thurner syndrome was considered based on the absence of blood dyscrasias and sustained anatomical changes found in the left common iliac vein at its junction with the right common iliac artery. A week following discharge, she presented with chest pain and was diagnosed with venous thromboembolism. The patient was successfully treated with anticoagulation therapy and insertion of a vena cava filter.

BACKGROUND: Daily pain and multi-site pain are both associated with reduction in work ability and health-related quality of life (HRQoL) among adults. However, no population-based studies have yet investigated the prevalence of daily and multi-site pain among adolescents and how these are associated with respondent characteristics. The purpose of this study was to investigate the prevalence of self-reported daily and multi-site pain among adolescents aged 12-19 years and associations of almost daily pain and multi-site pain with respondent characteristics (sex, age, body mass index, HRQoL and sports participation).

METHODS: A population-based cross-sectional study was conducted among 4,007 adolescents aged 12-19 years in Denmark. Adolescents answered an online questionnaire during physical education lessons. The questionnaire contained a mannequin divided into 12 regions on which the respondents indicated their current pain sites and pain frequency (rarely, monthly, weekly, more than once per week, almost daily pain), characteristics, sports participation and HRQoL measured by the EuroQoL 5D. Multivariate regression was used to calculate the odds ratio for the association between almost daily pain, multi-site pain and respondent characteristics.

RESULTS: The response rate was 73.7%. A total of 2,953 adolescents (62% females) answered the questionnaire. 33.3% reported multi-site pain (pain in > 1 region) while 19.8% reported almost daily pain. 61% reported current pain in at least one region with knee and back pain being the most common sites. Female sex (OR: 1.35-1.44) and a high level of sports participation (OR: 1.51-2.09) were associated with increased odds of having almost daily pain and multi-site pain. Better EQ-5D score was associated with decreased odds of having almost daily pain or multi-site pain (OR: 0.92-0.94).

CONCLUSION: In this population-based cohort of school-attending Danish adolescents, nearly two out of three reported current pain and, on average, one out of three reported pain in more than one body region. Female sex, and high level of sports participation were associated with increased odds of having almost daily pain and multi-site pain. The study highlights an important health issue that calls for investigations to improve our understanding of adolescent pain and our capacity to prevent and treat this condition.

Background Back pain is a common condition during childhood and adolescence. The causes of back pain are largely unknown but it seems plausible that some physical factors such as back muscle strength, back muscle endurance and aerobic capacity may play a role in its development, in particular in the early years.

Objectives The objectives of this review were to investigate in childhood and adolescence 1) if muscular strength in trunk extension is associated with back pain, 2) if muscular endurance in trunk extension is associated with back pain and 3) if aerobic capacity is associated with back pain.

Design Three systematic critical literature reviews with one meta-analysis.

Methods Systematic searches were made in June 2014 in PubMed, Embase and SportDiscus including longitudinal, retrospective or cross-sectional studies on back pain for subjects <20 years. Articles were accepted if they were written in French or English. The review process followed the AMSTAR recommendations. The possibility of conducting a meta-analysis was assessed for each research question.

Results Four articles were included for the first objective, four for the second and three for the last. None of the included articles found an association between back muscle strength in extension and back pain. For the second objective, a protective association between back muscle endurance in extension and back pain was found, later confirmed in a meta-analysis (OR = 0.75, 95 % CI 0.58-0.98). The association between aerobic capacity and back pain is not clear.

Conclusions High back muscle endurance in extension appears protective of back pain in youngsters, but the roles of high back muscle strength in extension and aerobic capacity are less clear.

Pain is relatively common in childhood and adolescence [1]. For example, in a population of circa 3000 adolescents, 61 % reported musculoskeletal pain at least in one area [2]. Back pain (BP) was noted to be the second most common type with 25 % reporting daily complaints [2]. BP is common during childhood and has been shown to be a predictor of low back pain (LBP) in adulthood [3]. Therefore, more knowledge is needed about BP in the early years, as attention needs to be focused on this period of life.

The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain

Clinical Associate Professor,
Faculty of Medicine,
School of Population and Public Health,
University of British Columbia

Introduction

Within mainstream health care, the customary management of low back pain (LBP) by primary care medical physicians is often not evidence based. Interestingly, clinical practice guidelines (CPG) for the treatment of acute mechanical LBP, for example, have been developed independently by multidisciplinary expert panels in 12 countries. [1-12]

The recommendations from those guidelines have been further accompanied by rigorous systematic reviews of the evidence [13-15] rather than expert consensus alone, [1] and, to date, they have generally endorsed the use of the following conservative modalities:

Despite widespread dissemination of CPG for LBP, compliance with this knowledge in general and with the SMT component in particular has been limited among mainstream health care providers. This is particularly true among family medical physicians, [16-18] whose personal beliefs about effective LBP care are often discordant with what is known from external research evidence. [19, 20] Yet, ironically, family medical physicians account for most office visits for LBP in many North American jurisdictions. [21]

INTRODUCTION: A few spinal manipulation techniques use paraspinal surface thermography as an examination tool that informs clinical-decision making; however, inter-examiner reliability of this interpretation has not been reported. The purpose of this study was to report inter-examiner reliability for classifying cervical paraspinal thermographic findings.

RESULTS: Overall inter-examiner reliability was fair (k=0.43). There was good agreement for identifying full pattern (k=0.73) and fair agreement for adaptation (k=0.55). Poor agreement was noted in partial categories (k=0.05-0.22).

CONCLUSION: Inter-examiner reliability demonstrated fair to good agreement for identifying comparable (full pattern) and disparate (adaptation) thermographic findings; agreement was poor for those with moderate similarity (partial). Further research is needed to determine whether thermographic findings should be used in clinical decision-making for spinal manipulation.

From the FULL TEXT Article:

Introduction

Doctors of chiropractic (DCs) use complex clinical decision-making when determining where, when, and when not to perform spinal manipulation. [1] Factors considered may include the diagnosis, symptom severity, presence of co-morbid conditions, patient preferences, and other examination findings [2, 3] such as static or segmental motion palpation, [4, 5] posture analysis, leg length analysis, [6] biomechanical interpretation of spinal radiographs, the presence of spinal/paraspinal tenderness, and abnormal muscle tone. [7] Some chiropractic spinal manipulation techniques, particularly those focusing on upper cervical manipulation, use thermographic and other diagnostic instruments to provide primary information to determine whether treatment should or should not occur. [8] The use of unique diagnostic instrumentation is not new to the chiropractic profession. B.J. Palmer, considered the “developer” of chiropractic, used an instrument called the electroencephaloneuromentimpograph and later, the neurocalometer. [9] The neurocalometer was the predecessor of the current nervo-scope, which is still used by some practitioners using the Gonstead technique system. [10, 11]

Happy Independence Day!

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

There have been a few studies regarding detail of back pain in adolescents with idiopathic scoliosis (IS) as prevalence, location, and severity. The condition of back pain in adolescents with IS was clarified based on a cross-sectional study using a questionnaire survey, targeting a total of 43,630 pupils, including all elementary school pupils from the fourth to sixth grade (21,893 pupils) and all junior high pupils from the first to third year (21,737 pupils) in Niigata City (population of 785,067), Japan.

32,134 pupils were determined to have valid responses (valid response rate: 73.7%). In Niigata City, pupils from the fourth grade of elementary school to the third year of junior high school are screened for scoliosis every year. This screening system involves a three-step survey, and the third step of the survey is an imaging and medical examination at the Niigata University Hospital.

In this study, the pupils who answered in the questionnaire that they had been advised to visit Niigata University Hospital after the school screening were defined as Scoliosis group (51 pupils; 0.159%) and the others were defined as No scoliosis group (32,083 pupils). The point and lifetime prevalence of back pain, the duration, the recurrence, the severity and the location of back pain were compared between these groups.

The severity of back pain was divided into three levels (level 1 no limitation in any activity; level 2 necessary to refrain from participating in sports and physical activities, and level 3 necessary to be absent from school). The point prevalence was 11.4% in No scoliosis group, and 27.5% in Scoliosis group. The lifetime prevalence was 32.9% in No scoliosis group, and 58.8% in Scoliosis group. According to the gender- and school-grade-adjusted odds ratios (OR), Scoliosis group showed a more than twofold elevated odds of back pain compared to No scoliosis group irrespective of the point or lifetime prevalence of back pain (OR, 2.29; P = 0.009 and OR, 2.10; P = 0.012, respectively).

Scoliosis group experienced significantly more severe pain, and of a significantly longer duration with more frequent recurrences in comparison to No scoliosis group. Scoliosis group showed significantly more back pain in the upper and middle right back in comparison to No scoliosis group. These findings suggest that there is a relationship between pain around the right scapula in Scoliosis group and the right rib hump that is common in IS.

From the Full-Text Article:

Introduction:

Most patients with adolescent idiopathic scoliosis (AIS) visit the hospital when a trunk deformity, such as rib or lumbar hump and waist asymmetry, is pointed out either after the school screening or by family members, and it is rare for these patients to visit the hospital due to back pain. However, some adolescent patients with idiopathic scoliosis (IS) do complaint of back pain in outpatient clinics. Previously, it had been accepted that special attention should be paid to patients with scoliosis who experienced back pain, because it was thought that might be additional pathologies such as an occult syrinx, spinal cord tumors, or neuromuscular disorders [4, 6, 20].

As you may have read previously, a major step forward for the profession occurred in July 2014 when the Department of Veterans Affairs began piloting a chiropractic residency program at five locations.1-2 This program is the result of years of dedication and strategic planning by the VA chiropractic leadership, and is congruent with the VA’s mission to train providers to serve the VA and the nation at large.

As the inaugural class, we are honored to have participated in the first phase of the three-year pilot program.

In March 2015, we had the opportunity to gather for a VA meeting held in advance of the Association of Chiropractic Colleges /Research Agenda Conference in Las Vegas. At this meeting, we worked with representatives from VA Central Office, the five residency program directors, and representatives from each program’s academic affiliates: Logan University, New York Chiropractic College, Southern California University of Health Sciences and the University of Bridgeport.

After this, many of us attended the ACC/RAC conference itself, where we participated in workshops and observed several cutting-edge research presentations. In our interaction with many of the ACC/RAC attendees, we noted a tremendous amount of interest in the VA Chiropractic Residency Program. We received questions ranging from inquiries about our future career plans to how perspective residents may apply. The following are some of the most frequent questions we fielded, as well as personal residency experiences.

A $712 million bust, the biggest in U.S. history, shows that the people most likely to bilk the system are doctors and medical providers, not “welfare queens.”

A specter is still haunting American politics—the mythological specter of the welfare queen. Even after Clinton-era welfare reforms, and despite an ever-growing list of state restrictions on how public benefits can be used, Americans remain convinced that there’s waste, fraud, and abuse in the system, and that stronger controls would keep undeserving citizens from bilking the taxpayer. There is fraud, it’s true. But it’s not nearly large enough to make a dent in the federal budget, and it’s not freeloading welfare queens who are taking advantage of the system.

Nearly lost Thursday in the response to the atrocity in Charleston was Attorney Loretta Lynch’s announcement of arrests in what she called “the largest criminal healthcare fraud takedown in the history of the Department of Justice.” A total of 243 people were arrested and charged with stealing $712 million from Medicare. The arrests included 46 doctors, nurses, pharmacy owners, and other medical professionals. Facilities billed the federal government for therapy sessions where patients were actually just moved, never treated. In a particularly disturbing case, a Michigan doctor allegedly “prescribed unnecessary narcotics in exchange for patients’ identification information, which was used to generate false billings. Patients then became deeply addicted to the prescription narcotics and were bound to the scheme as long as they wanted to keep their access to the drugs.”

Traumatic brain injuries are perplexing and problematic — and they affect millions of Americans. It has been estimated that up to 3.8 million Americans incur mild traumatic brain injuries (MTBI) or concussions in sports-related activities and approximately 50 percent of the injured do not report the injury to a health care professional. [1] I suspect that millions of MTBI are not reported to health care providers as a result of sporting activities, motor vehicle accidents, work-related injuries and military operations. Another report claims that MTBI affects more than 1.125 million Americans.

Traumatic brain injury is frequently referred to as the silent epidemic because the problems that result from it (e.g., impaired memory) often are not visible. Mild traumatic brain injury (MTBI) accounts for at least 75 percent of all traumatic brain injuries in the United States.

According to existing data, more than 1.5 million people experience a traumatic brain injury (TBI) each year in the United States. These injuries may cause long-term or permanent impairments and disabilities. Many people with MTBI have difficulty returning to routine, daily activities and may be unable to return to work for many weeks or months. In addition to the human toll of these injuries, MTBI costs the nation nearly $17 billion each year. [2]

Some of the current definitions, position statements and evidence-based guidelines regarding concussion and mild traumatic brain injury are offered for your perusal and consideration. Sources discussing treatment, prevention and living with traumatic brain injuries are provided for those interested in more detail, continuing education credits and certification. The goal of this article is to make more visible your patients with obscure MTBI symptoms. I hope that this article will reduce confusion regarding the diagnosis and treatment of patients with MTBI and concussions.

Bloodless Concussion: The Misunderstood Injury

Some 11 years ago, an excellent review, Bloodless Concussion: The Misunderstood Injury, pointed out that approximately two-thirds of all chiropractic physicians practicing in the United States are licensed to diagnose and treat patients as portal-ofentry health care providers. Consequently, they can assume a major role in evaluating, diagnosing and treating concussions, particularly head injuries that affect the spine and related extremities. The review by David Martinez, DC, focused on concussion and MTBI primarily related to sports injury and chiropractic medicine. He mentioned that it is difficult to diagnose concussion and oftentimes perceived as unimportant because no blood or other obvious clinical signs are visible. [3]

Vagus nerve stimulation that affects the immune system has wide implications for non-drug therapy in conditions such as Rheumatoid Arthritis.

By MICHAEL BEHAR

One morning in May 1998, Kevin Tracey converted a room in his lab at the Feinstein Institute for Medical Research in Manhasset, N.Y., into a makeshift operating theater and then prepped his patient — a rat — for surgery. A neurosurgeon, and also Feinstein Institute’s president, Tracey had spent more than a decade searching for a link between nerves and the immune system. His work led him to hypothesize that stimulating the vagus nerve with electricity would alleviate harmful inflammation. “The vagus nerve is behind the artery where you feel your pulse,” he told me recently, pressing his right index finger to his neck.

The vagus nerve and its branches conduct nerve impulses — called action potentials — to every major organ. But communication between nerves and the immune system was considered impossible, according to the scientific consensus in 1998. Textbooks from the era taught, he said, “that the immune system was just cells floating around. Nerves don’t float anywhere. Nerves are fixed in tissues.” It would have been “inconceivable,” he added, to propose that nerves were directly interacting with immune cells.

Nonetheless, Tracey was certain that an interface existed, and that his rat would prove it. After anesthetizing the animal, Tracey cut an incision in its neck, using a surgical microscope to find his way around his patient’s anatomy. With a hand-held nerve stimulator, he delivered several one-second electrical pulses to the rat’s exposed vagus nerve. He stitched the cut closed and gave the rat a bacterial toxin known to promote the production of tumor necrosis factor, or T.N.F., a protein that triggers inflammation in animals, including humans.

“We let it sleep for an hour, then took blood tests,” he said. The bacterial toxin should have triggered rampant inflammation, but instead the production of tumor necrosis factor was blocked by 75 percent. “For me, it was a life-changing moment,” Tracey said. What he had demonstrated was that the nervous system was like a computer terminal through which you could deliver commands to stop a problem, like acute inflammation, before it starts, or repair a body after it gets sick. “All the information is coming and going as electrical signals,” Tracey said. For months, he’d been arguing with his staff, whose members considered this rat project of his harebrained. “Half of them were in the hallway betting against me,” Tracey said.

Inflammatory afflictions like rheumatoid arthritis and Crohn’s disease are currently treated with drugs — painkillers, steroids and what are known as biologics, or genetically engineered proteins. But such medicines, Tracey pointed out, are often expensive, hard to administer, variable in their efficacy and sometimes accompanied by lethal side effects. His work seemed to indicate that electricity delivered to the vagus nerve in just the right intensity and at precise intervals could reproduce a drug’s therapeutic — in this case, anti-inflammatory — reaction. His subsequent research would also show that it could do so more effectively and with minimal health risks.

Tracey’s efforts have helped establish what is now the growing field of bioelectronics. He has grand hopes for it. “I think this is the industry that will replace the drug industry,” he told me. Today researchers are creating implants that can communicate directly with the nervous system in order to try to fight everything from cancer to the common cold. “Our idea would be manipulating neural input to delay the progression of cancer,” says Paul Frenette, a stem-cell researcher at the Albert Einstein College of Medicine in the Bronx who discovered a link between the nervous system and prostate tumors.

DCs Treating the Multiple Sclerosis Patient

Multiple Sclerosis (MS) is the most common disabling neurological disease of young adults, according to the National Institutes of Health (NIH), most often appearing when people are between 20 and 40 years old. However, it can also affect children and adults over 40. The U.S. National Library of Medicine defines MS as an autoimmune disease that affects the central nervous system (brain and spinal cord). The myelin sheath, a protective membrane that wraps around the axon of a nerve cell, is destroyed in a patient with MS; this is caused by inflammation. That damage causes nerve signals to slow down or stop. MS affects women more than men.

Since doctors of chiropractic are recognized as primary contact neuromusculoskeletal specialists, most will have patients with undiagnosed MS come into their practices. The DC will diagnose the patient, treat certain symptoms and make the appropriate referrals.

Diagnosis

Diagnosis of MS is complicated in that it can be severe or mild and can go into remission. NIH points out that initial symptoms often are double or blurred vision, red-green color distortion or blindness in one eye. Most MS patients experience muscle weakness in their extremities and difficulty with coordination and balance.

According to Larry Wyatt, DC, DACBR, FICC, professor and senior faculty, division of clinical sciences at Texas Chiropractic College, MS is diagnosed in a number of ways, as its clinical course is distinctive in each patient and there are different types of MS. Some patients with obvious MS are diagnosed by clinical signs and symptoms (i.e., attacks) alone. These patients will have MS attacks that often relapse for months or even years. In other patients further testing is necessary. Magnetic resonance imaging (MRI), often with gadolinium enhancement, is the mainstay of diagnosis in most cases. “Patients with MS will very often have multiple high-signal intensity lesions in the brain and/or spinal cord on T2-weighted images,” Dr. Wyatt says. “In addition, cerebrospinal fluid analysis for immunoglobulin content can be quite helpful. There is a specific set of criteria, called the McDonald Criteria, which outline the findings necessary for the diagnosis of the different forms of MS.”

Jason West, DC, DCBCN, a fourth-generation DC who operates a clinic in Pocatello, Idaho, says the majority of the diagnosis comes from the patient history, but he points out that usually when patients with MS come in, they already are diagnosed and they are unhappy with their medical treatment options. “If they weren’t diagnosed, one of the standards is to do an MRI and look for white lesions, and there is also a spinal tap to look for antibodies,” Dr. West says. “Usually these patients have a history of peripheral neuropathy or neurological disease or processes occurring.”